Fill - Free fillable Travel Packet 4-2017 PDF form

Cerritos College Revised 04/2017 Page | 1

ASSOCIATED STUDENTS OF CERRITOS COLLEGE TRAVEL PACKET

Name of Acvity/Conference:

Date of Acvity/Conference:

Departure Date:

/ /

Departure Time:

Return Date:

/ /

Return Time:

SECTION 1: TRAVEL INFORMATION:

First and Last Name:

Date of Birth:

/ /

Student ID No.

Phone Number:

( ) -

SECTION 2: PERSONAL INFORMATION

Are you at least 18 years of age?: Yes No

If you checked “No,” please ll out Secon 8

Street Address:

City:

State:

Zip Code:

Email Address:

Print Parcipant’s Name:

Parcipant’s Signature:

In the event of any medical emergency, I grant Cerritos College or any of its representaves on the trip the full

authority to take any acon deemed necessary to protect my health and safety at my expense, including but not

limited to place me (the parcipant) under the care of a doctor in a hospital at any place for medical

examinaon and/or treatment, or returning me to my home city at my own expense if such return is deemed

necessary aer consultaon with medical authories.

SECTION 3: MEDICAL CONSENT

Date:

/ /

Will you be taking District provided transportaon?:

Yes No

If you checked “No,” please ll out

Secon 7

If taking any prescripon

medicaon, list here:

Cerritos College Revised 04/2017 Page | 2

By inialing here, you are agree to the terms stated in the Aendance Agreement:

I understand that I am aending this conference/retreat/event as a representave of Cerritos College and that

the students aending Cerritos College have paid my expenses. Therefore, my failure to aend the conference or

leave early from the conference for anything other than a medical emergency will result in my having to reim-

burse the Cerritos College District for all my expenses for not aending the conference/retreat/event.

I understand that I am to conduct myself in a responsible many and agree to the following:

 I am currently enrolled in a minimum of 5 units at Cerritos College, have a 2.0 GPA and have a Cerritos Col-

lege I.D. card with a current semester scker.

 Aendance is required at all conference workshops.

 All cell phones will be turned o during presentaons and workshops. Use of cell phones during the work-

shops or any presentaon is prohibited and may result in conscaon of cell phone during the conference.

You may use your cell phones during free me.

 NO ALCOHOLIC BEVERAGES or ILLEGAL DRUG USE: California State Educaon Code prohibits alcoholic bever-

ages or illegal substances being consumed during a college funcon regardless of student age. (For the Stu-

dent’s Protecon, prescripons should be registered on the medical consent form).

 No inappropriate behavior will be allowed, nor any behavior that would endanger others or myself. I will

abide by the published Student Code of Conduct. Will be nancially responsible for the replacement cost of

any damage done to the conference/retreat facilies.

 No outside visitors will be permied to parcipate in the conference/retreat/event acvies.

Failure to comply with these guidelines may result in my returning home immediately, at my own expense.

SECTION 4: ATTENDANCE AGREEMENT

By inialing here, you understand that failure to comply with these guidelines may

result in you returning home at your own expense:

Parcipant’s Signature:

Date:

/ /

SECTION 5: CODE OF CONDUCT FOR COLLEGE & ASCC SPONSORED ACTIVITIES

Please review the Code of Conduct found on this link:

hp://cms.cerritos.edu/uploads/Board/Board%20Policies/Chapter%205/BP_5500.pdf

I have read and I am aware of the stated rules and regulaons in the Standards of Student Conduct found by ac-

cessing the link above, and the specic requirements for the acvity in which I am to parcipate. Any violaon of

these regulaons will subject me to disciplinary acon, which could include suspension and/or expulsion and any

violaon of any of these secons permission to be on campus or to aend campus acvies shall be seemed im-

mediately revoked.

Parcipant’s Signature:

Date:

/ /

Cerritos College Revised 04/2017 Page | 3

SECTION 6: HOLD HARMLESS AND INDEMNIFICATION AGREEMENT

This agreement is between the student and Cerritos Community College District (herein aer referred to as

“District”). The student does hereby covenant and agree that the District, its’ ocers, agents, employees,

members or representaves shall not be liable for any loss, damage, injury or liability of any kind to any person or

property caused by or arising from this acvity. Nor shall the District be liable for any loss, damage, or injury from

any cause whatsoever to the property of persons of this acvity or any of its employees or agents resulng from

this acvity. Notwithstanding anything to the contrary contained herein, the student agrees to defend, idenfy

and hold harmless the District, its ocers, employees and agents from any and all damages or liabilies arising

out of or connecon with this acvity.

Print Parcipant’s Name:

Parcipant’s Signature:

Date:

/ /

SECTION 7: NON-DISTRICT TRANSPORTATION NOTICE (IF APPLICABLE)

The undersigned hereby acknowledges and understands that Cerritos Community College District is NOT provid-

ing transportaon to a District Sponsored acvity and that it is the responsibility of the undersigned to a arrange

for transportaon.

The undersigned acknowledges and understands the driver is not driving on behalf of, or as an agent of, the Dis-

trict. Further, the undersigned understands that the District has not veried the driving record of the driver or the

mechanical condion of the vehicle.

It is fully understood that the District is in no way responsible, nor does the District assume liability, for any inju-

ries or losses resulng from this non-district sponsored transportaon. Although, the District may assist in coordi-

nang the transportaon and/or recommend travel me, route, or caravanning to or from this event, I fully un-

derstand that such recommendaon are not mandatory

Parcipant’s Signature:

Date:

/ /

Cerritos College Revised 04/2017 Page | 4

Allergies to drugs, food, insect

sngs, bites, or any other allergies:

Medical Condions for which

minor is currently being treated:

Current Medicaons and Dosage:

Restricons on Acvies:

Special Dietary Needs:

Physician’s Name:

Physician’s Phone Number:

( ) -

Physician’s Address:

Insurance Company:

Policy Number:

SECTION 8: CONSENT FOR TREATMENT OF A MINOR (IF APPLICABLE)

I/We hereby authorize Cerritos College Student Health Services to act as my/our agent to consent to any X-ray

examinaon, anesthec, medical or surgical diagnosis or treatment, and hospital care which is recommended

by, and to be rendered under the general or special supervision of, any licensed physician or surgeon, whether

such diagnosis or treatment is rendered at the Student Health Services facility or at a hospital

I/We understand that this authorizaon is given in advance of any specic diagnosis, treatment, or hospital care

being required, but is given to provide authority to the above-named agent to give consent to any and all such

diagnosis, treatment, or hospital care which a licensed physician recommends.

This authorizaon is given pursuant to the provisions of Family Code secon 6910.

I/We authorize any hospital providing treatment to the parcipang minor pursuant to the provisions of Family

Code secon 6910 to surrender physical custody of the minor to the parcipang agent upon the compleon of

treatment. This authorizaon is given pursuant to Health and Safety Code secon 1283.

Relaonship to minor:

Parent

Guardian

Other

Describe legal

relaonship:

These authorizaons shall remain eecve unl stated date unless

sooner revoked in wring delivered to the agent named above:

/ /

Signature:

Date:

/ /

Cerritos College Revised 04/2017 Page | 5

SECTION 8: CONSENT FOR TREATMENT OF A MINOR (CONTINUE)

Parent/Guardian Name #1:

Parent/Guardian #1 Cell Phone:

( ) -

Work Phone:

( ) -

Parent/Guardian #1 Address:

City:

State:

Zip Code:

Parent/Guardian Name #2:

Parent/Guardian #2 Cell Phone:

( ) -

Work Phone:

( ) -

Parent/Guardian #2 Address:

City:

State:

Zip Code:

Cerritos College Revised 04/2017 Page | 6

CODE OF CONDUCT FOR COLLEGE & ASCC SPONSORED ACTIVITIES

The President/Superintendent shall establish procedures for the imposition of discipline on students in accordance with the re-

quirements for due process of the state and federal laws and regulaons. The procedures shall clearly define the conduct that is sub-

ject to discipline, and shall identify potential disciplinary actions, including but not limited to the removal, suspension, or expul-

sion of a student. A complainant or witness who participates in an investigation of sexual assault, domestic violence, dating

violence, or stalking will not be subject to disciplinary sanctions for a violaon of the District’s student conduct policy at or near the

me of the incident, unless the District determines that the violaon was egregious, including but not limited to, an acon that places the

health or safety of any other person at risk or involves plagiarism, cheang, or academic honesty. Due process requires that in all signif-

icant disciplinary situations a student is informed of charges against him/her, is given an opportunity to refute them, and has the

opportunity to appeal a decision. The Board of Trustees shall consider any recommendation from the President/Superintendent

for expulsion. The Board of Trustees shall consider an expulsion recommendation in closed session unless the student re-

quests that the matter be considered in a public meeting. Final action by the Board of Trustees on the expulsion shall be taken

at a public meeting. The procedures shall be made widely available to students through the College catalog and other means.

Students enrolling in Cerritos College assume an obligation to abide by all District regulations on District-owned or controlled

property or at District-sponsored or supervised functions. Students who fail to adhere to District regulations are subject to disci-

plinary actions. In all disciplinary actions, the student shall be informed of the nature of the charges against him/her and given a

fair opportunity to refute them. The District shall not be arbitrary in its actions. The following conduct while on District-owned or

controlled property or at District- sponsored or supervised functions shall constitute good cause for discipline, including but not

limited to the removal, suspension, or expulsion of a student.

1. Assault, battery, or any threat of force or violence, or causing, attempting to cause, or threatening to cause physical injury to

another person, in person or in an online environment and, when the victim or victims are associated with the District, wheth-

er or not the location is associated with the District.

2. Possession, use, sale, or otherwise furnishing any firearm, knife, explosive, or other dangerous object or chemical, including

but not limited to any facsimile firearm, knife, or explosive on District-owned or controlled property or at District- sponsored or

supervised functions without the prior authorization of the President/Superintendent or designee.

3. Unlawful possession, use, sale, offer to sell, or furnishing, or being under the influence of, any controlled substance listed in

Chapter 2 (commencing with 48 Section 11053) of Division 10 of the California Health and Safety Code, an alcoholic bever-

age, or an intoxicant of any kind; or unlawful possession of, or offering, arranging, or negotiating the sale of any drug para-

phernalia, as defined in California Health and Safety Code, Section 11014.5.

4. Committing or attempting to commit robbery or extortion.

5. Theft, attempted theft of, or willful damage to District property or property in the possession of, or owned by, a member of the

college community or knowingly receiving stolen property or private property on District premises.

6. Willful or persistent smoking in any area where smoking has been prohibited by law or by regulation of the District.

7. Sexual assault or sexual exploitation regardless of the victim’s affiliation with the District.

8. Committing sexual harassment as defined by law or by District policies and procedures in person or in an online environment

and, when the victim or victims are associated with the District, whether or not the location is associated with the District.

9. Engaging in harassing or discriminatory behavior based on national origin, religion, age, gender, gender identity, gender

expression, race or ethnicity, color, medical condition, genetic information, ancestry, sexual orientation, marital status, physi-

cal or mental disability, pregnancy, or because he or she is perceived to have one or more of the foregoing characteristics,

or based on association with a person or group with one or more of these actual or perceived characteristics, or any other

status protected by law in person or in an online environment and, when the victim or victims are associated with the District,

whether or not the location is associated with the District.

10.Engaging in intimidating conduct or bullying against another student through words or actions, including direct physical con-

tact; verbal assaults, such as teasing or name-calling; social isolation or manipulation; and cyberbullying.

11.Willful misconduct that results in injury or death to a student, client, patient, visitor, guest, or to District personnel or that

results in cutting, defacing, or other injury to 78 any real or personal property owned by the District or on campus.

12.Endangering a student, client, patient, visitor, guest, or District employee or contributing to or causing harm to the health,

safety, and/or well-being of such others.

13.Disruptive behavior, continual or willful disobedience and/or persistent defiance of the authority, habitual profanity or vulgari-

ty, or abuse of District personnel or where the presence of the student causes a continuing danger to the physical safety of

students or others.

14.Cheating, or engaging in other academic dishonesty including copying from another’s work; discussion prohibited by the

instructor; obtaining exam copies without permission; and using notes, other information, or devices that have been prohibit-

ed.

15.Misrepresentation and/or impersonation, including arranging for or allowing another individual to impersonate or otherwise

misrepresent himself or herself to be a student generally or to be a particular student either in person or in an online environ-

ment, and/or impersonating or otherwise misrepresenting oneself to be another person in person or in an online environ-

ment.

16.Plagiarism, in individual or group work or in a student publication, including the act of taking the ideas, words or specific

substantive material of another and offering them as one’s own without giving credit to the source.

17.Dishonesty; forgery; alteration or misuse of District documents, records, or identification; or knowingly furnishing false infor-

mation to the District.

18.Unauthorized entry upon, into, or use of District facilities, either in person or in an online environment.

Cerritos College Revised 04/2017 Page | 7

CODE OF CONDUCT FOR COLLEGE & ASCC SPONSORED ACTIVITIES (CONTINUE)

19.Lewd, indecent or obscene conduct on District-owned or controlled property; at District-sponsored or supervised functions; or

directed at and for the purpose of harming another individual or group associated with the District, whether carried out in per-

son or in an online environment, and whether or not the location is associated with the District.

20.Engaging in expression that is obscene; libelous or slanderous; or that so incites students as to create a clear and present

danger of the commission of unlawful acts on college premises, or the violation of lawful District administrative procedures, or

the substantial disruption of the orderly operation of the District.

21.Persistent, serious misconduct where other means of correction have failed to bring about proper conduct.

22.Unauthorized use of audio, video or other listening, recording or transmitting device in any classroom, service area or District

activity without prior consent of the instructor, service area manager, or activity advisor except as necessary for reasonable

accommodation.

23.Failure, as a person involved in sexual activity, to ensure that he or she has the affirmative consent of the other or others to

engage in the sexual activity. Lack of protest or resistance does not mean consent, nor does silence mean consent.

 Affirmative consent must be ongoing throughout a sexual activity and can be revoked at any time. The existence of a dating

relationship between the persons involved, or the fact of past sexual relations between them, should never by itself be as-

sumed to be an indicator of consent. “Affirmative consent” means affirmative, conscious, and voluntary agreement to engage

in sexual activity.

a. In the evaluation of complaints in any disciplinary process, it shall not be a valid excuse to alleged lack of affirmative

consent that the accused believed that the complainant consented to the sexual activity under either of the following

circumstances:

b. The accused’s belief in affirmative consent arose from the intoxication or recklessness of the accused.

c. The accused did not take reasonable steps, in the circumstances known to the accused at the time, to ascertain wheth-

er the complainant affirmatively consented.

 In the evaluation of complaints in the disciplinary process, it shall not be a valid excuse that the accused believed that the

complainant affirmatively consented to the sexual activity if the accused knew or reasonably should have known that the

complainant was unable to consent to the sexual activity under any of the following circumstances:

a. The complainant was asleep or unconscious.

b. The complainant was incapacitated due to the influence of drugs, alcohol, or medication, so that the complainant could

not understand the fact, nature, or extent of the sexual activity.

c. The complainant was unable to communicate due to a mental or physical condition.

25.Sexual assault, defined as actual or attempted sexual contact with another person without that person’s consent, regardless of

the victim’s affiliation with the college; and, effective January 1, 2016, regardless of whether such conduct is related to college

activity or college attendance; including, but not limited to, any of the following: (1) Intentional touching of another person’s

intimate parts without that person’s consent or other intentional sexual contact with another person without that person’s con-

sent. (2) Coercing, forcing, or attempting to coerce or force a person to touch another person’s intimate parts without that per-

son’s consent. (3) Rape, which includes penetration, no matter how slight, without the person’s consent, of either of the follow-

ing: (A) The vagina or anus of a person by any body part of another person or by an object. (B) The mouth of a person by a sex

organ of another person.

26. Sexual exploitation, defined as a person taking sexual advantage of another person for the benefit of anyone other than that

person without that person’s consent, regardless of the victim’s affiliation with the college; and, effective January 1, 2016, re-

gardless of whether such conduct is related to college activity or college attendance; including, but not limited to, any of the

following: (1) Prostituting another person. (2) Recording images, including video or 169 photograph, or audio of another per-

son’s sexual activity, intimate body parts, or nakedness without that person’s consent. (3) Distributing images, including video

or photograph, or audio of another person’s sexual activity, intimate body parts, or nakedness, if the individual distributing the

images or audio knows or should have known that the person depicted in the images or audio did not consent to the disclosure

and objected to the disclosure. (4) Viewing another person’s sexual activity, intimate body parts, or nakedness in a place where

that person would have a reasonable expectation of privacy, without that person’s consent, and for the purpose of arousing or

gratifying sexual desire.

27.Misrepresentation of oneself or of an organization to be an agent of the District.

28.Continued disruption on or off District property of the District’s educational or 180 student services activities, administrative

functions and procedures, public service functions, authorized curricular or co-curricular activities, other functions, or prevention

of authorized guests from carrying out the purpose for which they are on District property.

29.Abuse of any person or any possession of any person, on District-owned or controlled property.

30. Violation of state or local laws, Board policies, or administrative procedures concerning the registration of student organiza-

tions, the use of District facilities, or the time, place, and manner of public expression.

31. Abusive behavior directed toward coercion of, or hazing of, or bullying of a member of the college community, in person or in

an online environment and, when the victim or victims are associated with the District, whether or not the location is associated

with the District.

Cerritos College Revised 04/2017 Page | 8

32.Violation of Board policies or administrative procedures governing the use of student user accounts, computers, and telecom-

munication resources, including but not limited to the unauthorized entry, opening, or viewing of a file; the unauthorized use of

another individual’s identification and password; arranging for, allowing, and/or impersonation of one person by another; send-

ing obscene or abusive messages or files; and/or use of computing facilities to interfere with the work of another student or

employee of District.

33.Engaging in physical or verbal disruption, intimidation, or harassment of such severity or pervasiveness as to have the purpose

or effect of unreasonably interfering with a student’s academic performance, or District employee’s work performance, or of

creating an intimidating, hostile or offensive educational or work environment, in person or in an online environment and, when

the victim or victims are associated with the District, whether or not the location is associated with the District.

34.Violation of a duly issued restraining order, stalking, and/or a pattern of conduct with intent to follow, alarm, or harass another

person, and which causes the person to reasonably fear for his or her safety, and where the pattern of conduct persisted after

the person has demanded that the pattern of conduct cease.

35.Failure to identify oneself when requested to do so by District officials acting in the performance of their duties.

36.Any other cause not listed above which is identified as “Good Cause” by the Education Code or that disrupts the college, its

mission, or campus life.

Office of Primary Responsibility: Dean of Student Services, Elizabeth Miller

CODE OF CONDUCT FOR COLLEGE & ASCC SPONSORED ACTIVITIES (CONTINUE)

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